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General NPI Number Information
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NPI Number | 1184972465
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Entity Type | Organization
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Legal Business Name | RONALD J FLACK LLC
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Dates
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Enumeration Date | 08/17/2012
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Last Update Date | 08/17/2012
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Provider Practice Location Address
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Address Line | 762 W MICHIGAN AVE
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City | JACKSON
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State | MI
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Zip | 49201-1978
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Country | US
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Telephone | 517-782-8142
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Fax | 517-782-0765
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Provider Business Mailing Address
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Address Line | 762 W MICHIGAN AVE
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City | JACKSON
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State | MI
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Zip | 49201-1978
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Country | US
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Telephone | 517-782-8142
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Fax | 517-782-0765
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Authorized Official
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Title or Position | BILLER
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Name | LAURA ETUE
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Credential |
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Telephone | 517-522-8582
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 4704149271
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License Number State | MI
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